Weaving the DNA of #Healthcare. Learn about front-line clinical informatics, clinical workflow design, and EMR implementation with an experienced CMIO. Open discussion is encouraged, education is a priority. All opinions are strictly my own.

Monday, May 9, 2016

At some point, most CMIOs, CNIOs, and other informatics professionals get asked to speak about topics related to healthcare technology. One of the topics I'm very passionate about is medication safety, so when I was recently asked by HomeWatch Caregivers and CareOne at Northampton to present on medication safety at transitions of care - I jumped at the chance!

At CareOne Northampton MA - May 4, 2016

Why do medication errors occur? What human factors and systems issues contribute to medication safety issues? And what can organizations do to help reduce them? To help answer these questions, I've posted the slides from my May 4th, 2016 CEU presentation at CareOne in Northampton below, along with some commentary (and helpful links) in between them. If you're looking for ways to further improve medication safety in your organization, I hope these slides are helpful to you!

First, to open the talk - a few slides about the presentation, and who I am :

Talk about topical - The day before my presentation, Dr. Martin Makary reported in the BMJ ( BMJ 2016;353:i2139, published 3 May 2016) that medical errors are now the third leading cause of death (behind heart disease and cancer) - This article underscores the importance of understanding where errors come from, and how to prevent them!

So first, to understand how to talk about medication errors, it's helpful to talk about how to manage medications correctly : I call it the "Five RIGHTS of medication safety" - Giving the RIGHTmedication at the RIGHT dose via the RIGHT route/method to the RIGHT patient at the RIGHT date/time. One could even add the Right Manner, and Right Reason/indication to this discussion, but to keep things simple, I've presented the five biggest sources :

So given that understanding of the goal, why do errors occur? Heuristics aside, what are the challenges in assembling and reconciling a "home medication list" on admission? Let's first look at the Five Rights, which will then help us understand where errors can occur :

Thank you to the Institute of Safe Medication Practices (www.ismp.org) for providing the samples of illegible handwriting above - I highly recommend their web site, which is a treasure trove of important information about medication safety...Finally, a few other potential sources of error :

Which then brings us to the discussion on single source-of-truth (SSOT) - A discussion which is key in understanding the challenges, pitfalls, and opportunities in managing medications at transitions of care, and inside an organization :

... and the importance of maintaining this/these source(s)-of-truth at all times :